Association Between Primary Care Practice Telehealth Use and Acute Care Visits for Ambulatory Care-Sensitive Conditions During COVID-19

Abstract

Importance: During the COVID-19 pandemic, many primary care practices adopted telehealth in place of in-person care to preserve access to care for patients with acute and chronic conditions. The extent to which this change was associated with their rates of acute care visits (ie, emergency department visits and hospitalizations) for these conditions is unknown.

Objective: To examine whether a primary care practice's level of telehealth use is associated with a change in their rate of acute care visits for ambulatory care-sensitive conditions (ACSC visits).

Design, setting, and participants: This retrospective cohort analysis used a difference-in-differences study design to analyze insurance claims data from 4038 Michigan primary care practices from January 1, 2019, to September 30, 2020.

Exposures: Low, medium, or high tertile of practice-level telehealth use based on the rate of telehealth visits from March 1 to August 31, 2020, compared with prepandemic visit volumes.

Main outcomes and measures: Risk-adjusted ACSC visit rates before (June to September 2019) and after (June to September 2020) the start of the COVID-19 pandemic, reported as an annualized average marginal effect. The study examined overall, acute, and chronic ACSC visits separately and controlled for practice size, in-person visit volume, zip code-level attributes, and patient characteristics.

Results: A total of nearly 1.5 million beneficiaries (53% female; mean [SD] age, 40 [22] years) were attributed to 4038 primary care practices. Compared with 2019 visit volumes, median telehealth use was 0.4% for the low telehealth tertile, 14.7% for the medium telehealth tertile, and 39.0% for the high telehealth tertile. The number of ACSC visits decreased in all tertiles, with adjusted rates changing from 24.3 to 14.9 per 1000 patients per year (low), 23.9 to 15.3 per 1000 patients per year (medium), and 27.5 to 20.2 per 1000 patients per year (high). In difference-in-differences analysis, high telehealth use was associated with a higher ACSC visit rate (2.10 more visits per 1000 patients per year; 95% CI, 0.22-3.97) compared with low telehealth practices; practices in the middle tertile did not differ significantly from the low tertile. No difference was found in ACSC visits across tertiles when acute and chronic ACSC visits were examined separately.

Conclusions and relevance: In this cohort study that used a difference-in-differences analysis, the association between practice-level telehealth use and ACSC visits was mixed. High telehealth use was associated with a slightly higher overall ACSC visit rate than low telehealth practices. The association of telehealth with downstream care use should be closely monitored going forward.

Figure 1.. Unadjusted Rate of Aggregate Ambulatory Care–Sensitive Condition (ACSC) Visits Over Time by Level of Practice Telehealth Use

Data are based on an analysis of Blue Cross Blue Shield of Michigan claims for 2019 to 2020. Low, medium, and high telehealth tertiles are derived from primary care practice telehealth use from March to August 2020 compared with 2019 visit volume, weighted by number of patients per practice.

Figure 2.. Average Marginal Effect of Practice Telehealth (TH) Use, Practice Characteristics, and Patient Characteristics on Ambulatory Care–Sensitive Condition (ACSC) Visits per 1000 Patients per Year

Data are based on an analysis of Blue Cross Blue Shield of Michigan claims for 2019 to 2020. The primary outcome is the average marginal effect of the interaction between TH tertile (low, medium, or high) and the study period. The average marginal effects of the other covariates are shown for comparison. Error bars indicate 95% CIs. CHF indicates congestive heart failure; COPD, chronic obstructive pulmonary disease; IP, in-person; and TIN, taxpayer identification number.